Process Safety
Management
Valerie Orr
Shazad Barghi
Ralph Buchal
Prepared for MINERVA November 2013
Introduction
Module Outline
What is PSM?
Importance of PSM
PSM Systems
Rules, Regulations, and Guideline for PSM in
Canada
References and further reading
2
MODULE OUTLINE:
PROCESS SAFETY MANAGEMENT
Description:
This module is meant to provide an introduction to process safety management (PSM).
In a very simple sense, PSM is a framework for identifying and managing process risks.
It is a type of safety management system that is specific for the process industries.
Therefore, the principles are relevant to all disciplines of engineering involved in a
process facility and are also broadly applicable to other manufacturing industries. The
ultimate goal of PSM is to prevent the occurrence of major hazard incidents which are
not appropriately addressed through traditional occupational health and safety
procedures. This is due to the fact that many serious unplanned incidents are many
times not simply attributable to any individual operator error. PSM strives to ensure all
hazards of a process are identified and effectively managed for the lifetime of the
process, regardless of changes in personnel, organization, or environment. The
principles of PSM as taught in this module are based on a particular reference from the
American Institute of Chemical Engineers Center for Chemical Process Safety (AIChE
CCPS).
3
Primary Reading Materials:
RISK BASED PROCESS SAFETY MANAGEMENT (2007)
 Introduction to the twenty elements of PSM developed by the American Institute
of Chemical Engineers Center for Chemical Process Safety
SAFETY MANAGEMENT: A COMPREHENSIVE APPROACH TO DEVELOPING A
SUSTAINABLE SYSTEM (2012)
 A comprehensive look at the factors that affect safety improvements and the
effectiveness of a process safety management system. Large focus on the human
factors which affect the adoptions of safe work practices, such as leadership and
behavior.
4
Chapter Title
1 Introduction
Contents




The importance of PSM in the prevention of major
hazard incidents
Brief History and recent examples
Rules and Regulations for PSM in Canada
PSM Systems
Elements of Process Safety Management
2 Commitment to PSM
3 Hazard Identification and Risk
Assessment
4 Risk Management
5 Enhancing PSM
1.
2.
3.
4.
5.
6.
7.
Process safety culture
Compliance
Competence
Workforce involvement
Stakeholder outreach
Hazard identification & risk management
Knowledge management
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Operating procedures
Training & performance
Safe work practices
Asset integrity & reliability
Contractor management
Management of change
Operational readiness
Conduct of operations
Emergency preparedness
Incident investigation
Auditing
Metrics & measurements
Management review
5
 PSM is the proactive application of management
principles to a process for the prevention of loss of
containment events
 PSM is a system for dealing with:
What is
Process
Safety
Management
(PSM)?
“… human performance in complicated systems that
involve inherent risk”
– Aviation Safety Expert and Pilot Chelsey Sullenberger
(Interview on the application of aviation systems safety
lessons to medicine CBC Radio 2013)
 This applies to the process industries too
 Any site which stores, handles or manufactures
hazardous substances or energy will have an inherent
risk
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
6
 A loss of containment incident (LoC) occurs when a
harmful substance or energy is released outside of
the equipment which is meant to contain it [1,2,3,4]
Loss of
Containment
 In some countries the amount of substance released
dictates whether the incident is reportable to the
government
 Also, in some countries, the amount of hazardous
material contained in either equipment or at a
facility can determine if implementation of PSM
systems is required; e.g., Environment Canada
Environmental Regulations, US OSHA PSM Rule
1910.119 [3, 5]
7
 Faulty gauge causes an overfill of a storage tank
spilling 10000 kg of ethanol
 2000 kg of crude oil leaks from corroded piping
Examples of
PSM
incidents
Introduction
 Operator opens process valve and causes acid spill
and gets burned
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
8
 PSM systems are meant for
industries handling, storing,
or manufacturing hazardous
substances
Intent of
PSM
 Hazardous substances are
defined by their reactivity,
toxicity, flammability, or
other dangerous properties
by the Canadian
Environmental Protection
Act Part 8 Section 200 [5]
PSM is primarily intended for the process industries
and is typically applied at a facility level
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
9
PROACTIVE
PSM is a
Proactive
Risk Based
Approach
REACTIVE
• Implementing
countermeasures to
prevent an incident
• Implementing
countermeasures after an
incident has occurred
• Perform hazard analysis
and risk assessment
• Perform incident
investigation and determine
root cause
• Practice inherently safer
design
• Design & install additional
layers of protection after an
incident
[1]
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
10
PSM is a subset of system safety
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
11
OCCUPATIONAL HEALTH & SAFETY
PROCESS SAFETY
 Individual-oriented & controlled
 Focused on direct interaction between
individual and equipment or structures
 Specific impact
 Work place rules & safety equipment
 Worker training & supervision




Examples of Possible Incidents
Examples of Possible Incidents
•
•
•
•
•
•
•
•
•
•
Fall
Spill
Electrocution
Asphyxiation
Hearing Impairment and other chronic
injuries
Minor injuries (pinch, banged knee, etc.)
Examples of Safeguards
•
•
•
•
Hazardous Work Permits
Personal Protective Equipment
Ventilation systems, confined space entry
Guardrails, equipment guards
Introduction
Commitment
to PSM
[5,6, 7]
Cooperative
Broad impact
Systems
Little individual control
Explosion
Release of hazardous chemical
Fire
Release of hazardous energy
Examples of Safeguards
DESIGN
OPERATIONS
•
•
•
•
Pressure Safety Valves
Inherently Safer Design
Equipment Interlocks
Process Alarms
Hazard & Risk
Assessment
Risk
Management
•
•
•
•
Maintenance
Inspections
Training
Procedures
Enhancing
PSM
12
 PSM is important because loss of containment events
in the process industries can have DIRE consequences
for employees, the public, and the company.
Why is PSM
Important?
Introduction
 Several major chemical catastrophes have
demonstrated the need for effective PSM and the
potential devastation of a dysfunctional system
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
13
A few major industrial accidents
INCIDENT
EFFECTS
Bhopal, India, 1984
Union Carbide
Methyl Isocyanate Release
>3800 fatalities, >100 000 injuries, severe damage to
area livestock and crops, long term health effects,
$470 M compensation
Chernobyl, USSR, 1986
Nuclear Reactor Meltdown
30 acute fatalities, >130 000 people exposed to
harmful radiation, long term health affects,
permanent evacuation of the city
11 fatalities from the explosion
Extensive environmental damage, extensive damage
to regional fishing and tourism industry, >$4.5 B USD
in fines, >$42 B in civil settlements
Loss of crew (7 fatalities), loss of space shuttle (>$8 B
USD), recovery of debris
Gulf Oil Spill. USA, 2010
British Petroleum
Deepwater Horizon Oil Platform
Explosion and Spill
Challenger Disaster, USA, 1986
NASA
Explosion
[8, 9]
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
14
Bhopal India, 1984
 Union Carbide Corporation
operating in Bhopal
manufactured methyl isocyanate
(MIC) as a precursor in Sevin
(insecticide) production [8, 9].
 Over >40 tons of MIC leaked into
the air and caused over 3800
immediate fatalities and
countless injuries and long term
health affects.
MIC tanks after Bhopal incident. (Wikipedia commons)
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
 Management had intentions to
permanently shut down
uneconomical operations and
while many safety designs were
not kept in operation even
though a substantial MIC
inventory was still in place
Risk
Management
Enhancing
PSM
15
On the night of the accident, approximately 2000 L
of water was introduced into the MIC storage tanks
causing an exothermic reaction to produce MIC
vapours and increased pressure [8].
How did this
happen?
 There is no consensuses on how the water was
improperly introduced into the tanks. Some
suggestions include valve malfunction or sabotage.
 Regardless, safety considerations had been made in
the design of the plant. The MIC storage tanks were
equipped with a soda scrubber, a refrigeration
system, and temperature and pressure alarms.
 However, the scrubber was out of service. The
flare, being the last defence, was also not in service.
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
16
 Production had been halted 6 months prior to the
accident and the downstream Sevin plant continued
to operate using the stored MIC. This indicated that
considerable amounts of MIC a highly toxic chemical
was being stored for extended period of time.
How did this
happen?
Introduction
 Inherently safer design (ISD) dictates that inventory
of highly toxic materials should be maintained at
the lowest possible level to minimize the possibility
of large releases. Also, newer technology was later
developed to produce the same pesticide product
without using MIC intermediate, thus employing
the ISD principle of substitution.
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
17
 Accountability and corporate commitment to
safety failed when supervisors failed to take
immediate action when workers first reported a
burning sensation in their eyes.
Why did this
happen? (In
terms of
PSM)
Introduction
 No management of change system was used to
evaluate the effects of shutting down the safety
equipment such as the refrigeration system, the
soda scrubber and the flare system while continuing
to store a significant amount of MIC on-site.
 Equipment integrity and operating procedures
were not maintained and as a consequence the
pressure alarms had become so unreliable they
were ignored by workers, the temperature alarms
had failed to operate, and the tanks were filled
beyond their recommended capacity
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
18
Flixborough, UK, 1974
 Napro UK located in
Flixborough manufactured
caprolactam a precursor for
nylon synthesis [4,8,9,10].
 An improperly designed
bypass line caused the leakage
of a 50 ton cyclohexane
vapour cloud in seconds
Allen, B. (2011). Flixborough: The price of nylon. Health and Safety at work.
 Upon contact with an
ignition source, the resulting
explosion killed 28
employees and damaged
over 1800 buildings in the
surrounding area.
Link to official report http://www.catastrophic-events.com/docs/Flixborough.pdf
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
19
 Prior to the accident, a crack in the reactor used for
the oxidation of cyclohexane was discovered.
 The maintenance engineer on-site decided to install
a bypass line in order to maintain production and
reduce down time.
How did this
happen?
 However, the site experienced mechanical engineer
had quit some time before, and those remaining
decided to “fast track” a solution for the by-pass.
 For design, they sketched a full-scale by-pass line in
chalk on the maintenance shop floor.
 However, no stress and thrust force analysis
calculations were performed on the by-pass line.
 The bypass later ruptured and leaked hot
cyclohexane into the vicinity which ignited resulting
in the explosion.
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
20
 A functional PSM system would require a
management of change system to deal with
process design changes.
Why did this
happen? (In
terms of
PSM)
Introduction
 Every facility must ensure that competent personnel
are hired and trained for the positions they fill.
 Proper management of organizational change
would have identified that the maintenance
engineer, and the laboratory manager who also
reviewed the shop floor sketch design, were
unqualified
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
21
What are some of the consequences of
major hazard incidents?
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
22
Health and Safety
Workers are at highest risk of injury since they are at the “front line.” The
public while not on-site is at risk when a serious major disaster occurs.
Worker
•
•
•
•
Death
Severe injury
Long term health problems
Affects personal monetary success if injuries and health problems
interfere with future work
Public
•
•
•
•
•
•
Death
Severe injury
Long term health problems
Economic problems
Community longevity
Environmental health will also affect the public’s health and safety
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
23
Environmental Impacts
[9]
Environmental damage caused by major disasters can harm residents’ health as
well as lead to reduced longevity of the community
Atmospheric
•
•
•
Contamination of air quality used by humans, animals and
vegetation
Contamination of property (e.g. soot)
Interference of normal quality of life and business
Aquatic
•
•
Contamination of water used for drinking, irrigation and recreation
Harm to fish and wildlife
Terrestrial
•
•
Contamination of land and vegetation
Property damage
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
24
Corporate Losses
[11,13]
A major disaster can completely ruin a company. At minimum be severely detrimental
to the well being of the organization and thus the employees
Clean Up
•
Clean up of the Deep Horizon spill & legal settlement fees cost >$14 B
USD
Insurance
•
•
•
A poor safety record increases premiums on assets
A poor safety record increases the number of health claims
Large amounts of claim settlements cause higher premiums
Reputation
•
The international news reporting ensures the disaster will be seen by
consumers around the world
May cause consumer boycott
Reputation as an employer that values safety
•
•
Productivity
•
Will decrease productivity and therefore profits if a facility is not
operational
Product Quality
•
•
May decrease quality if facility is not operating at top quality
May cause pressure on other facilities decreasing their quality
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
25
 PSM systems are typically centered around four
themes [4]:
i. Commitment of management and corporate
objectives to PSM
The
Elements of
PSM
ii. Hazard assessment, including process
knowledge and hazard identification
iii. Risk management such as managing change
in the process and change in personnel
iv. Continuous enhancement such as furthering
employee education and enhancing process
knowledge
THESE ARE THE TITLES OF THE REMAINING SECTIONS
OF THIS MODULE…. CLICK TO NAVIGATE
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
26
PSM System Possible Elements
[1, 2, 4]
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
27
Risk is never zero.
 Two of the most important features of a PSM system are participation and
communication
 Although PSM systems are typically designed by management they require
input from operators and commitment from corporate executives to be
implemented properly
 PSM systems are non-prescriptive [13]
 They must be based on performance indicators to measure the success of the
PSM system
 Guidelines can be implemented in many ways as long as the objectives are met
 Finally, PSM systems are not created once and implemented once.
 They are an on-going process that involves auditing and revaluation of the
management system to continually enhance the effectiveness of the PSM
system.
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
28
Process Safety Management Systems from
around the world
 American Occupational Health and Safety Administration Process Safety
Management Rule enacted in 1994
 14 Elements - CSChE – The Canadian Society for Chemical Engineering [1]
 20 Elements - AIChE CCPS – The American Institute for Chemical Engineers
Center for Chemical Process Safety [4]
 12 Elements – OSHA – US Occupational Health and Safety Administration
PSM Rule 1910.119 [3]
 20 Elements – EU Energy Institute [2]
 Some large corporations may also sell their custom systems or services for
implementing PSM
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
29
 While no specific regulations to implement PSM in
process facilities in Canada currently exist, nonetheless,
“due diligence” does require companies to make their
processes safe
Commitment
to Best
Practices
 Negligence or ignorance and failure to do a proper
assessment to prevent an incident can be a criminal
offense as described in the Criminal Code.
Bill C-45 – Amendment to the Criminal Code of Canada:
 "217.1 Every one who undertakes, or has the authority, to
direct how another person does work or performs a task
is under a legal duty to take reasonable steps to prevent
bodily harm to that person, or any other person, arising
from that work or task.“ [14]
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
30
 Bill C-45 was passed as a result of the Westray Mine
Explosion in Nova Scotia, 1992
 About 8 months after the mine was opened, an
underground methane explosion killed 26 workers
who were underground at the time. There were no
survivors underground [15].
Westray Bill
 A public inquiry found that the mine was poorly
managed, worker safety was ignored, and poor
oversight by the government regulators were the
causes of the worse mining disaster in Canada
 A criminal case was pursued against two managers
but was dropped when it became unlikely they
would be convicted.
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
31
Responsible Care
 The Chemistry Industry Association of Canada (CIAC) promotes PSM as part of their
Responsible Care program for their members [6].
 Many companies may possess facilities in the United States which are required by law
since 1994 to have a functioning PSM system and are therefore experienced with the
development and implementation of these systems.
http://www.canadianchemistry.ca/ResponsibleCareHome.aspx
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
32
Two major international drivers of PSM:
 US OSHA PSM Standard 1910.119 [16]
PSM around
the world
 With the US OSHA levying hefty fines in the past few
years, the need for functional PSM systems is
increasing
 While no fines will be levied for failure to possess a
functional PSM system in Canada, there are still legal
requirements for all people directing work to take
reasonable steps to ensure worker and public safety
 EU Seveso II Directive [17]
 Directive II was a revision of the original directive
which increased the requirement to include a safety
management system, as well as emergency and
land-use planning
33
 In the event of a loss of containment, the criminal
code of Canada states that there will be severe
penalties for failing to ensure the safe operation of
facilities and ensure operational integrity [14].
PSM in
Canada
 Environment Canada’s Environmental Emergencies
regulation requires hazard assessments to prevent
spills, which is the focus of PSM.
 Ontario Environment Regulation 224 requires risk
assessment of potential spills and a contingency plan
 Alberta Strathcona County has bylaws requiring riskbased land use planning adjacent to hazardous
 Other bylaws and regulations may exist and should
be evaluated for every facility
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
34
Summary
How do we prevent a loss of containment
incident?
Maintain process integrity
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
35
References
 1. Canadian Society for Chemical Engineering. Process Safety Management
Guide. Ottawa : Canadian Society for Chemical Engineering, 2012.
 2. Energy Institute. High Level Framework for Process Safety Management.
London : Energy Institute, 2010.
 3. U.S. Department of Labor. Process Safety: (OSHA 3132). s.l. : U.S. Department
of Labor, 2000.
 4. Center for Chemical Process Safety. Guideline for Management of Change for
Process Safety. New York : John Wiley & Sons, Inc, 2008.
 5. Government of Canada. Canada Environmental Protection Act, 1999.
Environment Canada [Online] 07 10, 2013. http://www.ec.gc.ca/lcpecepa/default.asp?lang=En&n=E00B5BD8-1
 6. Chemistry Industry Association of Canada. Responsible Care. Chemistry
Industry Association of Canada. [Online] 07 10, 2013.
http://www.canadianchemistry.ca/ResponsibleCareHome.aspx.
 7. Government of Canada. Canada Occupational Health and Safety Regulations
(SOR/86-304). Justice Laws Website. [Online] 07 10, 2013. http://lawslois.justice.gc.ca/eng/regulations/SOR-86-304/.
 8. Atherton, John and Gil, Fredric. Incidents that define process safety. Hoboken,
NJ : John Wiley & Sons, Inc, 2008.
36
 9. Kletz, Trevor. What went wrong? Case histories of process plant disasters
and how they could have been avoided. 5th. Oxford : Elsevier, 2009.
 10. Oxford Economics. Potential Impact of the Gulf Oil Spill on Tourism.
Washington : US Travel Association, 2010.
 11. Health and Safety Executive. The Flixborough Disaster : Report of the
Court of Inquiry. London : Her Majesty’s Stationery Office National Archives,
1975.
 12. Turk, M.A. and Mishra, A. Process Safety Management: Going Beyond
Functional Safety. Hydrocarbon Processing. [Online] 07 23, 2013.
http://www.hydrocarbonprocessing.com/Article/3161534/Process-safetymanagement-Going-beyond-functional-safety.html.
 13. Sutton Technical Books. Process Safety Management. Sutton Technical
Books. [Online] 07 23, 2013. http://www.stb07.com/process-safetymanagement/process-safety-management-index.html.
 14. Department of Justice, Government of Canada. Plain Language guide to
Bill C-45. http://www.justice.gc.ca/eng/rp-pr/other-autre/c45/. Accessed:
May 30, 2013.
37
 15. Government of Nova Scotia. The Westray Story: A predictable path to
Disaster. http://novascotia.ca/lae/pubs/westray/. Accessed: June 2, 2013.
 16. U.S. Department of Labor. Process Safety: Regulation 1910 : U.S.
Department of Labor, 2000. [Online]
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STAND
ARDS&p_id=9760
 17. European Commision. EU Seveso II Directive. European Commision , 2013
[Online] http://ec.europa.eu/environment/seveso/index.htm
 18. Busick, Jennifer. Process Safety Management. SAFETY COMPLIANCE LETTER.
pp. 5-6.
 19. Kelly, Brian D. Process Safety Management and its impact on the
professional engineering community. Calgary, Ontario, Canada : s.n., 2010
38
Commitment to
Process Safety
Process Safety Culture
Compliance with Standards
Process Safety Competency
Workforce Involvement
Stakeholder outreach
39
 Evolution of organizational culture [1, 2]
Commitment
to process
safety
Introduction
Confrontational/Enforcement
↓
Cooperative/Collaborative
 Develop safety culture to consistently follow
existing standards, involve the entire workforce
and communicate with stakeholders
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
40
1. Process Safety
Culture
The way in which safety is managed and
perceived in a workplace
41
The goals of a sound process safety culture are to [1]:
 Monitor and maintain a sound safety culture
Process
Safety
Culture
Introduction
 Support the consistent operation of the process
This is achieved by providing strong leadership and
direction, prioritizing process safety, providing
sufficient resources, and establishing performance
standards and enforcing them.
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
42
What does a strong safety culture look like?
Weak Culture
Strong Culture
•
Assigns little value to process safety
•
Has poor sense of process safety vulnerabilities •
•
Devotes minimal resources to process safety
•
•
Overlooks small indications of process safety
problems
•
•
Accepts or normalized increasingly poor safety •
performance
Relies solely on few individuals or management •
to determine process safety hazards and risk
management activities
•
Introduction
Commitment
to PSM
[1]
•
Integrates process safety into the core values of
the organization
Focuses on potential failures and strives to
understand the risk and means of controlling it
Seeks to provide resources proportional to the
perceived needs
Places emphasis on learning from mistakes in
order to prevent future problems
Seeks to continuously improve process safety
performance
Employees of all levels are involved in hazard
identification and addressing the risks.
Employees take action to address hazards at all
levels
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
43
[3]
STRONG
Organizational
Culture
Tribal
Operational
Excellence
Chaotic
Bureaucratic
People
WEAK
Introduction
Commitment
to PSM
WEAK
Systems
STRONG
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
44
 Strong leadership is required in order to establish
process safety as a core value of the organization
 An essential feature of good safety leadership is
CREDIBILITY:
 What you say must be aligned with what you do
 Senior & middle management must be on the same page
 Executives and CEOs must possess strong will to make the
right decision in the face of demands from shareholders
and stakeholders
Providing
strong
leadership
Introduction
Commitment
to PSM
Hazard & Risk
Assessment
Risk
Management
Enhancing
PSM
45
What gets rewarded gets done
 A balance of direction on production, facility, personnel,
and safety must be given in order to prevent a
reordering of priorities amongst middle managers and
supervisors [2]
Providing
direction
 When leaders focus exclusively on production, this
indirectly communicates that production should take
precedence over everything else
 This inhibits proactive preventive behaviours and
encourages a reactive culture
Introduction
Commitment
to PSM
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• A strong safety culture establishes a strong
intolerance for any violations of safe practice in order
to reinforce safety as a core value
Establishing
process
safety as a
core value
“A practitioner [engineer] shall, regard the practitioner’s
duty to public welfare as paramount” - Professional
Engineers Ontario Code of Ethics [4]
 Engineers should always be reinforcing the
organizations’ commitment to safety throughout their
professional activities
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Identifying your type of safety culture
[2]
Generative
Proactive
Calculative
Reactive
Pathological
“Safety is how
the business
is run”
“Safety is
managed by
workforce
involvement”
“Safety is
managed by
procedures &
documentation”
“Safety is only
an issue if
something
happens”
“Who cares as
long as you
don’t get
caught”
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 Leadership is the most important variable in changing
safety behaviours.
Leadership in
process
safety
Introduction
 A good safety leader [2]:
 Prioritizes safety
 Sets safety targets
 Creates the safety vision
 Provides compelling direction
 Provides sufficient resources (such as people,
time, money, or information)
 Weathers the impact of shareholder/stakeholder
punishment on investments on improving safety
and quality until it gains support upon maturity
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2. Compliance
with Standards
Following the law, rules, and regulations
as well as any existing professional or
design standards
50
 This is a fundamental requirement for organizations [5]
Compliance
with
standards
 Relevant rules, regulations, and standards must be:
I.
Identified
II. Understood
III. Implemented or confirmed
 Non-compliance typically results in fines but can also
lead to serious accidents
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Why should
you comply?
Because tragic accidents have taught us
they could have been prevented if best
practices were followed
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 Licensing
What types
of
regulations &
rules exist?
Introduction
 Permit systems
 Codes for equipment
 Pressure vessels
 Piping, etc.
 Government requirements
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3. Process Safety
Competency
Process safety competency focuses on
organizational learning. It is distinct from the
training and knowledge elements which
focus on cataloguing and storing information
and maintaining worker competency
respectively.
54
The main purpose is to UNDERSTAND
What is the
purpose of
process
safety
competency?
Introduction
 The purpose of process safety competency is to
proactively increase the body of knowledge of an
organization prior to any incident occurring [1]
 Additionally, this knowledge seeking must be
supported by management and applications of
newly acquired knowledge should be encouraged in
order to reduce risk and increase process safety
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Positive Learning Culture
[1,6]
Establishes and periodically updates the
learning plan
Supports discussion and evaluation of
divergent opinions and data
Help focus the efforts to increase
competence
Stimulate new ideas
Provide timely feedback
Allow feedback on the means to improve
how work activities are approached
Tolerating errors
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Don’t depend only on incremental
approaches to improve PSM
Maintains an external focus
Ideas from outside the organization
are not automatically discounted
Learns from errors. Failure to
encourage innovation stifles
improvement
Introduction
Recognize and accepts differences
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Negative Learning Culture
[1,6]
Blind spots
Narrow focus and poor assumptions
allow disruptive technologies
Flawed interpretation
Poor logic due to lack of
information or emotional bias
Filtering
Downplaying information that doesn’t
fit in the existing paradigm
Inaction
Unwilling or unable to act
Lack of information sharing
Hoarding information and poor
sharing
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4. Workforce
Involvement
Involving all levels in the activities of
process safety management
58
 The purpose of workforce involvement is engage
employees of all levels in the development or
revaluation of PSM elements
Purpose of
workforce
involvement
 The workforce also includes and contract workers
that will be affected by facility operations
 Employees at different levels will contribute
different information about the process that is
necessary in order to create an effective PSM
system
 Frontline workers may be the best authority on day
to day operations and routines
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How to do
you involve
people in
PSM?
Introduction
 Provide specific PSM responsibilities to their roles
[1, 7]
 Provide a mechanism for individuals to
communicate their concerns or observations
 Allow individuals to participate in protecting their
own welfare
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 Individual empowerment [1,2]
 Everyone should feel they have a say in their own
welfare and safety
 Deference to expertise
Benefits of
workforce
involvement
 Recognize expertize or lack of it when evaluating
process safety
 Open communication
 Encourage participation in safety discussions
 May be that only 1 person realizes the risk
 Mutual trust
 Foster trust between workers and management
 Responsiveness
 Improve participation in safety by providing sincere
timely response to PSM input or concerns
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It applies to
all elements!
 Generally is involved in all aspects of PSM and not
really specifically addressed by this element alone
 Element specific activities may involve periodic
opinion surveys
 Evaluation of worker involvement
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5. Stakeholder
outreach
Providing a means of communication for
the concerns of any stakeholders
63
Who may be affected by your facilities
operations?
Government Officials
Non-government associations
• Local councils
• Politicians
• Regulators
Emergency Response Services
• Business/Industry
associations
• Environmental groups
• Youth groups
Other
• Residents
• Post-secondary
institutions
• Local school
boards
• Fire
• Paramedics
• Police
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Why is
stakeholder
outreach an
element of
PSM?
 Following the events of Bhopal, India, it was evident
that the potential for damage to the surrounding
community was immense and that chemical
producers had an obligation to hear the concerns of
the community
 The Chemistry Industry Association of Canada
(formerly the Canadian Chemical Producers
Association) created a mandatory initiative called
Responsible Care which calls for Community
Awareness & Emergency Response practices
http://www.canadianchemistry.ca/ResponsibleCareHome.aspx
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 The main objectives of the outreach element are to
[1]:
Goals of
stakeholder
outreach
Introduction
1.
Identify and engage the community and other
stakeholders in discussions about process safety
2.
Establish a mode of communication for any
concerns of needs stakeholders may want
addressed
3.
Use the establish mode of communication to
follow up on any aired concerns
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TRUST
 Public discussion and openly addressing concerns
builds trust with the stakeholders [2]
Benefits of
stakeholder
outreach
 It is important for residents to feel confident that
the organization is taking reasonable care to
operate in a safe and environmentally sound way
 Promoting transparency and responsiveness will
increase the stakeholders confidence in the
company [1]
 This in turn may lead to the stakeholders willingness
to cooperate in the future
 Stakeholders will know how to contact the company
should the need arise
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 Communications personnel, phone operators,
security guards, legal staff [1]
Who does
this?
 Key personnel should receive communications
training in order to prepare them to hold planned
events to press conferences
 Legal personnel must give guidance to
communications personnel in order to protect
confidential business information while providing
the appropriate information for any concern
 Any additional staff such as those responsible for
emergency response planning
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Organizing
your
outreach
system
Introduction
 How an organization pursues their outreach will
depend on the size of the facility and the potential
risks for the community [1]:
 Combine with other industrial partners in the area
 Emergency response may require a separate
outreach format than other stakeholders
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 The outreach program will also be used in the
aftermath of an incident should one occur [1,2]
Press
Conferences
Introduction
 By engaging the public in the outreach program
prior to an incident, in a state of emergency, the
public will already be aware of the communication
plan of the facility
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 [1] Center for Chemical Process Safety. Guidelines for Risk
Based Process Safety. New Jersey : Jon Wiley & Sons, 2011.
 [2] Lutchman, C. et al. Safety Management: A
comprehensive approach to developing a sustainable
system. London: CRC Press,2012)
 [3] Ian Sutton. (2010) Process Risk and Reliability
Management: Operational Integrity Management. Elsevier.
References
 [4] Professional Engineers Ontario Code of Ethics, Section
77 of the O. Reg. 941
 [5] Energy Institute. High Level Framework for Process
Safety Management. London : Energy Institute, 2010.
 [6] Is yours a learning organization? Garvin, David A,
Edmondson, C Amy and Gino, Francesca. 2008, Harvard
Business Review, pp. 1-11.
 [7] Canadian Society of Chemical Engineering. Process
Safety Management Guide. Ottawa : Canadian Society of
Chemical Engineering, 2012.
71
Hazard and Risk
Identification
Process Knowledge Management
 Hazard Identification and Risk Analysis
72
 This pillar of PSM has two elements [1]:
Hazard and
Risk
Identification
Introduction
I.
II.
Process knowledge
Hazard Identification and Risk Assessment
 These two elements will form the bases of your risk
management activities and therefore,
comprehensive knowledge of your process and
proper identification of hazards and their risks is
crucial to PSM.
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6. Process
Knowledge
Identification and documentation of all
relevant process knowledge for use in
other PSM elements
74
 This element boils down to three things:
Process
knowledge
Management
Introduction
i. Understanding your process
ii. Documenting your understanding
iii. Managing the documentation process
 The results of this element should be [1]:
Commitment
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(1) Accurate, complete, up-to date information
about your process
(2) A documentation system
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What kind of knowledge is necessary? [1]
 Chemical materials
 Hazard information, MSDS Sheets
 Reaction chemistry
 Kinetics, thermodynamics, calculations
Process
Knowledge
 Process conditions
 Equipment design
 Design, fabrication and installation
 Engineering drawings & calculations
 Piping & Instrumentation Diagrams (PI&Ds)
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Managing your documentation
Documentation and access of information is just as important as understanding
your process [1]:
 Information that is up to date must be protected
 Access must be protected to avoid inadvertent change
 Scheduling a cycle for updating documentation may help
 Out of date information must be retrieved and controlled
 Access must be controlled to avoid circulation of incorrect knowledge
 Only kept for archival purposes
 Knowledge must be documented in a usable and easily retrievable manner, a.k.a
user friendly
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Consequences of poor process
knowledge management
 Process knowledge is critical to
identifying the hazards and risks
of a process
 Example: Hydroxylamine
explosion, Pennsylvania 1999 [1]
 4 employee fatalities, 1
employee of an adjacent
business killed
 14 injured, extensive damage to
the area
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Knowledge Translation
 Very first pilot scale batch of hydroxylamine distillation in this
facility
 It was documented that hydroxylamine in solutions of >70% (w/v)
undergo explosive decomposition
 The process was designed to distill hydroxylamine to 85% (w/v)
Knowledge was not properly managed
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7. Hazard
Identification and
Risk Analysis
Identify process hazards and evaluate
process risks.
80
 These terms are often used interchangeably,
however they are not the same thing [1]
Hazards &
Risks
 A hazard can be any chemical use, physical action,
mechanical process, etc. that could, upon a failure
event, cause damage to a person(s), property, or
the environment
 Risk is the probability that someone, property or
the environment may suffer harmful consequences
as a result of exposure to a hazard
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Car accidents
• A car accident is a common physical hazard we have
all seen. Lets specifically refer to one car hitting
another car.
Example:
Car Accident
• The risk of being in a collision is dependent on several
factors; road conditions, driving ability, vehicle
engineering design, etc.
• However, in general, you might have (for example) a
1:1000 person chance of being in a collision.
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 The only way to have zero
risk is to never ride in a
car so you can never be
involved in a car/car
collision.
Zero Risk
 The likelihood that you
will never get in a car is
pretty much zero (in
Canada). So this is rarely
true.
 If a process is operating,
the risk can never be zero.
The only way to eliminate
process risks is to never
run the process.
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 The consequences will depend on your speed, road
conditions, vehicle design, etc.
Severity or
Consequences
 Therefore, the bigger the consequences the higher
the risk.
 E.g. the faster you are going, the worse you could
get hurt so you are taking a larger risk.
 This is called the severity :
𝑅𝑖𝑠𝑘 = 𝑃𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑥 𝑆𝑒𝑣𝑒𝑟𝑖𝑡𝑦
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𝑅𝑖𝑠𝑘 = 𝑃𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑥 𝑆𝑒𝑣𝑒𝑟𝑖𝑡𝑦
Two possibilities:
Increasing
Risk
a.
↑ probability = ↑ risk
 E.g. probability of a collision is higher in winter;
so the collision risk is higher
b.
↑ severity = ↑ risk
 E.g. the accident’s severity is worse if you don’t
wear your seatbelt; so the collision risk is higher
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Why is hazard identification important?
If you don’t know what the risks
are, you can’t manage them!
What is the risk that the dealer has blackjack?
Should you take the risk and bet? Does the risk
change if the stakes are high?
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PERCEIVED RISK vs. ACUTAL RISK
Risk
• Incorrect hazard identification or risk assessment
can lead to unknowingly accepting more risks than
the company or community has deemed
acceptable.
• It can also waste time & money!
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Risk Assessment Matrix
Consequences
Catastrophic
←
Serious
←
Negligible
High
↑
Frequency
Moderate
↑
Low
 The unacceptable risk region is set by an organization’s risk tolerance criteria
 This table describes the basics of risk assessment. For example, If the risk falls into the black zone,
it’s not an acceptable risk, however, in between are lots of shades of grey.
 Risk analysis determines the expected frequency (or likelihood) as well as the severity for a particular
consequence
 Risk assessment compares the risk result level to an acceptable risk criteria
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 Residual risks
 The risk you are willing to tolerate to operate your
facility
 For example there is always an inherent risk will
building a new fertilizer plant
 Introduced risks
 Risks which are introduced during the lifecycle of a
process
 New equipment or changes in personnel
Four Types of
Risk [4]
 Operating risks
 Risks caused by your operational procedures
 Normalized risks
 Risks that are deviations from the normal risk but
become normalized over time. Caused by
incomplete understanding of the actual risk.
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Some of the many TOOLS of PHA [1]
 Simple hazard identification:
Process
Hazard
Analysis
(PHA)
 Hazard and Operability Analysis (HAZOP)
 Failure Modes and Effects Analysis (FMEA)
 What If Studies
 Simple risk analysis:
 Layers of Protection Analysis (LOPA)
 Failure Modes, Effects, and Criticality Analysis (FMECA)
 Detailed quantitative risk analysis can use:
 Fault Tree Analysis (FTA)
 Monte Carlo Simulation and Markov Analysis
 Quantitative hazard effects analysis
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 The need for a PHA is usually assessed by a steering
committee who have identified a need for PHA in
some areas
 PHAs are typically administered by a team lead
Who conducts
a PHA?
 Engineers, Operations, and Maintenance staff will
all be involved from necessity in generating the
information required for a PHA
 The team lead will gather the data and the
information and recommendations are reported to
management
 Senior management will ultimately make a decision
on any policy changes
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Three general categories [3]:
 Logical/Rational
How do you
identify
hazards?
 Usually used for detailed PHAs
 E.g. Fault Tree Analysis is logical
 Experience-based
 Moderate depth, such as checklists.
 Known scenarios maybe from historical events at
the facility or similar facilities
 Creative/Imaginative
 What if analysis identifies new scenarios
 Broad general PHAs require this
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 Although we are trying to prevent serious
consequences from occurring in a process; in the
PHA, the causes can be relatively minor
Scope of
PHAs
 Does not refer to work place safety concerns such
as falling off a ladder and wearing PPE, unless they
are a potential cause in a larger hazard (very rare)
 In general, PSM is concerned with loss of
containment hazards, their causes and maintaining
process integrity
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Loss of Containment:
 Chemical Release
 Spills
 Energy Release
 Thermal (e.g., Fire)
 Physical (e.g., Explosion)
 Nuclear (e.g., Radiation)
Potential
Process
Hazards
 Special Case – Runaway Reactions
 Thermal runaway reactions (E.g. Chemical reactions
or nuclear reactions)
 A special case for the process industries which
manufacture chemicals
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Hazard:
Chemical
Release
 Release of a
hazardous
chemical
 Environmental
damage
tao55 / FreeDigitalPhotos.net
 Damage to
community
health and
welfare
Sujin Jetkasettakorn / FreeDigitalPhotos.net
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Nuclear
Mechanical (kinetic)
Electrical
Hazard:
Energy
Release
Chemical
jscreationzs/ Freedigitalimages.net
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An energy release from these sources can result in a:
Hazard:
Energy
Release
 Fire (thermal energy)
 Explosion (mechanical/ kinetic energy)
 (may have many ways of starting from various
sources)
 Radiation (nuclear energy)
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FIRE = FUEL + OXYGEN + IGNITION
 Fuel:
Hazards:
Fire
 Volatile Liquids
 Aerosol
 Dust
Combustible aerosols and dusts can ignite more easily
than some liquids.
Note, not commonly known: No liquid or solid can
burn! Only the vapour on the surface of the liquid/
solid, created by heat from the ignition process,
burns. The resulting fire sustains vapour
development.
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Fires are often started
for free:
Hazards:
Fire
 Heat (auto-ignition)
 Open flames (welding,
heaters, etc.)
 Electrical (sparks, static,
lightning, etc.)
tiverylucky / FreeDigitalPhotos.net
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A rapid release of energy manifested by high pressure
and high temperature [4]
 Chemical – Rapid oxidation reaction (often started
by a flame)
Hazard:
Explosion
 Mechanical or Vapor – Sudden rupture of
mechanical containment due to increased pressure
or weakened container wall
 Nuclear – Fission based explosion which cannot
happen outside of a weapon specifically designed
for this purpose (won’t happen in a nuclear power
plant)
 Electrical – High current electrical fault which
instantly vaporizes metal and insulating materials
 Magnetic – Magnetic pressure caused by ultra
strong electromagnets (unlikely to happen in a
chemical process plant)
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Initiating Causes
While loss of containment of chemicals and energy can lead to these
hazards, often there is an initiating cause that may not be directly related:
 Equipment failure
 Human errors
 External “acts of god”




Inclement weather (Tornado, hurricane, etc.)
Plane crash
Alien invasion
Missile Attack
dan/ FreeDigitalPhotos.net
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 This is a particular worry for
chemical process industries
Special
Case:
Thermal
Runaway
 Thermal runaway reactions
are a feedback loop
whereby heat is generated
by a reaction which
increases the reaction rate
which thereby creates more
heat at a greater rate, etc.
 The reaction goes out of
control, often resulting in
an explosion
 This is most often caused by
failure of the process heat
removal system
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(Wikipedia commons)
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Hazard:
Runaway
Reaction
“A chemical reaction process which accelerates out of
control in consequence of the release of chemical
energy at a rate which exceeds that which it can be
removed from the system by heat transfer
operations” [4]
 The term “runaway reaction” is specific to reactions
in vessels (because technically that definition is true
for a fire)
 This hazardous event has been seen in many
industrial accidents and is technically avoidable with
sound engineering design, but sometimes these
may be caused by human factors
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Hazardous Event Probability and Time Line
Inherent
Potential
Hazard
Initiating Causes
Freq. of initiating cause (process control
failure or procedural error)
Hardware Defense
Prob. of failure of interlock and
mechanical safety devices
Initiating
Cause
Operational
Hardware
Failure
Failure Mechanical
Loss of
Failure
Operational Defense
Containment
Prob. of failure to respond to
process alarms
Hardware Failure
Prob. of mechanical integrity
breach
Loss of Containment
Hazardous
Event
Freq. of loss of containment
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Using PHA
information
Introduction
 Once you know the hazards what do you do with
the information?
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Management
and PHAs
 Management is typically not just engineers that
understand the process. Decisions are made for the
facility based on competing interests
 PHAs that are accurate can be useful and necessary
to help management from making poor decisions
 Managers have to make decisions based on
competing interests
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Finances
Productivity
Competing
Interests
Quality
Consistency
DECISION
Safety
Regulatory
Requirements
Introduction
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Customers
Stakeholders
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Engaging the workforce
Senior Mmgt
Fallible
Decisions
Middle Mmgt
Engineers
Latent
Failures
Preconditions
Supervisors
Operators
Unsafe
System
Acts
Hardware
Failures
Defense
Accident
 Management decisions are critical [5]
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 Assessing risk is not simple. Different people will have
different opinions about severity and maybe even
frequency if it not easily quantified.
Risk is
mutable
Introduction
 Low frequency:
 Runaway reaction
 Should you protect your plant from a plane crash?
 Should you protect from natural hazards not typical to
your region? (e.g., hurricanes)
 Should you protect against missile attacks?
 Should you protect against a meteorite crash?
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Risk Management
 Risk can be controlled by operating practices and process design… a.k.a
Risk Management
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 [1] Center for Chemical Process Safety. Guidelines for
Risk Based Process Safety. New Jersey : Jon Wiley &
Sons, 2011.
 [2] Photo Credit: Tom Volk/The Morning
Call. http://www.mcall.com/all-concept1,0,7393.photo
References
 [3] Ian Sutton. (2010) Process Risk and Reliability
Management: Operational Integrity Management.
Elsevier.
 [4] Vic Marshall and Steve Ruhemann. (2001)
Fundamentals of Process Safety. iChemE.
 [5] Knegtering & Pasma (2009). Safety of the process
industries in the 21st century: A changing need of
process safety management for a changing industry. J
Loss Prevent Proc Ind. 22; 162-168.
111
Risk Management
Operating Procedures
Management of Change
Safe Work Practices
Operation Readiness
Asset Integrity and
Reliability
Conduct of Operations
Contractor Management
Training and performance
Assurance
Emergency Management
Risk Management
 Risk can be managed in many ways.
Generally the sooner in the process life cycle
you implement a risk management decision,
the cheaper it is.
 The most cost effective time to implement
safety features is during the design process
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 Use of Inherently safer design (ISD) principles seeks to avoid hazards
rather than control them with added-on protective equipment [1, 2]
 Minimize:
 Reduce inventories of hazardous materials on site
 Substitute:
 Replace hazardous substances, equipment or operations with less
hazardous ones whenever possible
Inherently
Safer Design
 Moderate:
 Use less aggressive operating conditions
 Simplify:
 Only use necessary operations. Remove issues by design not by the
addition of consequential process operations
Other strategies employed by ISD
 Design and locate equipment such that:
 Minimize transportation and storage of hazardous materials if
possible
 Locate equipment and materials such that in the worst possible
scenario the least amount of damage is done
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 Once upon a time a king offered three young men an
opportunity to take a chance for true love. They could
open one of two doors. [1]
 Behind one door was a dragon.
 Behind the other was their true love.
A tale of
RISK
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The first man decided not to take the risk. He lived
safely until the end of his days but he never found
love.
Inherently
Safer Design
The second young men hired some risk professionals.
They collected data on the tiger and the true love,
built machines to detect the sounds of a dragon and
calculated the probability. Naturally this took time
and money and the by the time the consultants were
ready to advise the man he was old and poor.
Regardless he opened the recommended door and
got eaten by a low probability dragon.
The third man took a course in dragon slaying.
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8. Operating
procedures
This element focuses on documenting
written procedures, maintaining them, and
consistently using them to maintain facility
integrity
117
 Current
Three Goals
 Accurate
 Useful
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 Normal operations
What types
are covered?
Introduction
 Infrequent operations
 Special high hazard procedures
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Ways to write procedures [3]
 Narrative
 Written in long paragraphs, difficult to
follow (most common but avoid this if
possible)
 Flowchart
 Graphical depiction with brief
descriptions
 Checklist
 Paragraph
 Basic actions with spots to initial
or check off actions
 Similar to narrative but given some
structure through numbering
 Playscript
 Outline
 Short sentences with number or
indentation structure to group
information
 For multiple operators that need
to perform tasks together
 T-Bar
 Multi-Column
 Multiple compartments of information
usually used for troubleshooting guides
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 Two columns one with steps,
other with details or special
instructions
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 For each step in a procedure, the following should
be outlined in the written protocol [3]:
Contents of a
Procedure
Introduction
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 Any expected system responses (or none)
 Indicators that the step was performed properly
 Possible consequences if the step was not
performed properly
 Safe operating limits
 Consequences of deviating from limits
 Any limiting conditions
 Address what procedure should be followed if
deviations from the limits is detected
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Validation & Maintenance
 Written operating procedures must be used consistently, therefore it is important to
validate that they conform to the actual procedures used. [3]
 However, the correct and safe practice should be the one finally reflected in the
procedure and should be implemented if not in actual practice. Once they are
implemented, ask for feedback from the operators to correct any errors or omissions.
 Procedures must be available to those using them and those you may need to use
them infrequently.
 They should be updated & reviewed regularly
 Old procedures must be controlled to ensure that only the correct practices are being
used.
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9. Safe work
practices
This element focuses on using safe work
procedures during maintenance or nonroutine work.
123
 This does not refer to the frequency of
the task
Non-routine
work
Introduction
 Any work that is not a part of the normal
operating process [3]:
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




Inspections
Calibrations
Repairs
Testing
Maintenance activities (specific procedures
are covered in the maintenance element)
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Three sets of procedures will help cover all
possibilities and reduce risk:
 Operating procedures (Element 8)
 Normal process operations
Cover all
your bases
 Safe work practices (Element 9)
 Non-routine work
 Maintenance procedures (Element 10)
 Maintenance of equipment (routine but
not part of normal operations)
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 Non-routine work should use a permit
system which must be authorized and
confirmed with the correct personnel prior
to the activity being undertaken [3]
Work
Permits
 Operators
 Technicians Performing Work
 Permits are updated at each shift change
 Permits also ensure the appropriate locks on
valves or switches are in place prior to the
work taking place
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Permits will require that safe work procedures
are used and this may involve placing a fire
blanket when welding to prevent ignition, for
example [3]
Other Things
Work
Permits
Control
 Confined space entry
 Hot work (Fire hazard)
 Welding, cutting with no fuel source present
 When flammables are present, welding,
drilling, grinding become an ignition hazard
 Opening vessels, lines, etc.
 Lock outs (electrical, valves. etc.)
 Construction (inside or adjacent to operating
areas)
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Piper Alpha Oil Platform Explosion, 1988
The explosion at Piper Alpha was caused by improperly managed
safe work practices for example, safety valve inspection/ testing.
 An offshore oil rig exploded resulting in 167 deaths and $1.7 B dollars in
damage [3]
 The explosion was caused by a hydrocarbon leak due to the removal of a
safety valve on a pump which was removed for inspection/ testing and not
reinstalled prior to the shift change.
 The pump had been taken out of service earlier that day for maintenance
work
 The night crew was aware of the maintenance work and had to authorize
electricians to resupply the pump with power in order to return it to service
 It is unclear if the night crew knew that the maintenance was incomplete
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10. Asset integrity
and reliability
This element focuses on the design,
installation and maintenance of
equipment from when it is fabricated to its
retirement to ensure it is fit for use
129
 VERY important element
Critical
Element
 Covers a major desire in process safety:
MAINTAIN PROCESS INTEGRITY
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 This has been a leading cause of
accidents in the process industries [3]
 Poor design
 Poor installation
 Poor maintenance
Equipment
Failure
 Undetected deterioration
 Improperly performed maintenance
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Managing
asset
integrity
 Inspections
 Testing
 Certifications
This is one of the two primary responsibilities of a
process facility [3]:
(1) Preventing a loss of containment incident
(2) Ensure the dependability of critical systems
that prevent these types of events
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American Airlines Flight 191, 1979
 Deadliest air crash in the US, 273 fatalities [1, 4]
 Caused by improper maintenance procedures
 In an attempt to save time and money, the
airline instructed maintenance mechanics to
remove the engine and pylon together instead of
doing it separately as indicated in the
maintenance procedures
 This resulted in a damaged pylon that was
undetected for several flights
• During the final takeoff, the pylon failed and the wing was ripped off during
takeoff causing the crash
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11. Contractor
management
The purpose of contractor management is
to ensure that contract workers work
according to safe work practices and that
they don’t increase the operational risk of
the facility
134
 Specialized skills
 Maintenance and Repairs
Why are
contractors
used?
 Construction
 Equipment Installation
 Janitorial Work
 Grounds keeping
 Many other reasons
[3]
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 Selection
Process of
Contracting
 Acquisition
 Use (& Training)
 Monitoring
[3]
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 Prequalify accredited firms
Contractor
Management
System
Introduction




Safety record
Strong safety culture
Employee turnover rate
Previous performance
 Encourage near-miss reporting among contractors.
They are the least likely to do so and most likely to
get hurt on the job [5]
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 The safety valve which was
removed earlier, was
removed by a contractor
that had been hired to
inspect/ test it.
Piper Alpha
Continued
[6]
Introduction
 The contractor had not
been trained properly in
the safe work practices
needed for the task.
 The incident investigation
also determined that the
inadequate emergency
response training given to
contractors on the rig
contributed to the high loss
of life
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12. Training and
performance
review
Training is required to ensure that workers
preform a task to a minimum standard, to
maintain their proficiency, or to upgrade
their skills. Performance reviews determine
when these actions are required.
139
 Practical instruction in job tasks or methods [3]
 Enable workers to meet minimum performance
standards
What is
training?
Introduction
 Performed before the worker is allowed to perform
the task on their own
 Followed by performance assurance to confirm that
the worker is performing the tasks correctly and
that they posses the knowledge, skills, and abilities
(KSAs) required for their position
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 Start by identifying the KSAs you are trying to
develop [3]
Developing
new training
 Identify or hire qualified personnel to develop
the materials.
 Procure training materials
 Develop training program/ course
 Develop ways to assess the KSAs post-training
 Validate the training by getting feedback from
workers that are currently considered qualified
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Other Elements
Job or Task
Analysis
Job
Requirements
Gap Analysis
New
Regulations
Incident
Investigation
Develop
Training
Program/
Course
Training
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Hazard & Risk
Assessment
Organizational
Change
Auditing
Assess
KSAs
Inadequate
Learning
Ability
Adequate Learning Ability,
periodic refresher training
Introduction
Management
Review
Reassign
Worker
Adapted from [3]
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13. Management of
change
This element proscribes a system for dealing
with all types of modification at a facility
from chemical supplier changes, facility
changes, to personnel changes
143
 Management of change (MOC) is critical for
preventing changes from increasing the facilities
risk of a loss of containment event
One of the
most
important
elements
Introduction
 MOC also helps a facility remain in compliance
with government regulations, the Responsible
Care initiative, and helps maintain other quality
initiative like ISO 9000 [7,8]
 MOC interacts with almost every other element
in the risk management area and also the
knowledge management element in the hazard
assessment section
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 A change request is made [7, 8]
 Qualified independent personnel (i.e. not the
requestor) review the request to identify any
additional hazards
Example
process
 The responsible party either reject or approves
the request based on the review
 If it is approved it can be implemented
 Prior to implementation the relevant operating
procedures or process safety documentation is
updated and the potentially affected personnel
are informed
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Process Life Cycle
Process
Development
Construction
Detailed
Design
Operating lifetime
Extended
Shutdowns
Decommissioning
Startup
 Many changes will occur throughout the lifecycle of a process facility. The
general stages are shown above. [3, 7, 8]
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 Sometimes emergency changes are necessary. [7,
8]
 Change must be implemented to prevent an
environmental release
 Correct a deficiency that an immediate threat to
the safety of workers
 The facility must be prepared for an external
threat (for example a tidal wave or flood)
Emergency
Changes
 Therefore it is useful to have an expedited
system. However to prevent unessential use of
the system, it should be a requirement to
complete the full request for change process as
soon as possible afterward.
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14. Operational
readiness
This element covers processes for
conducting pre-startup reviews of new
processes or processes that were
temporarily out of service
148
 Processes should be shutdown in a
way to confirm they are safe to
restart later [3]
 Duration of shutdown should be a
factor in the safety verification
Readiness
 Consider any modifications that we
necessary for shutting down the
process
 Likelihood of having an accident is
highest during process transitions
such as shutdowns and startups
 A readiness record makes it easy to
audit a process later and determine
potential issues
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 Verify current condition with equipment or design
specifications [3]
 Ensure all process procedures are in place
Prior to
startup (old
& new
processes)




Operating procedures
Safe work procedures
Emergency procedures
Maintenance procedures
 Ensure training is completed by operators which may
affect the process
 Confirm the process is safe to operate
 Inspections
 Cleanliness
 Isolation from potential hazards, etc.
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Verify [3] :
Equipment readiness (meets design
specs)
Process control systems
Emergency shutdown systems
Cleaning processes have been
complete (if applicable)
Equipment lineup is validated
Procedures are in place
Emergency response equipment is in
place
Training is up to date for all operators
that may affect the process
Readiness
Review
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 Have undergone full management of change
request & approval process [3]
New
Processes
Introduction
 All documentation has been updated
 PHA, where necessary, has been completed
 All equipment or safeguards have been installed
 Conduct pre-startup review prior to starting the
process
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15. Conduct of
operations
This element focuses on operational
discipline. This element is extremely
important in a field which is dependent on
operators performing their tasks correctly
every time.
153
 Workers are expected to perform with [3]:





Tied to
Organizational
Culture
Alertness
Due thought
Full knowledge
Sound judgement
Sense of accountability
 A workers ability to perform their tasks perfectly
repeatedly is dependent on the culture of the
organizations
 Mistakes cannot be tolerated in an environment
where small deviations could lead to catastrophic
results
 Formal operational activities are increasingly
required for consistent performance in complex
systems
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 Reliable and consistent
operations will also
benefit product quality
and productivity
Accountability
Introduction
 The conduct discipline
culture should
acknowledge that
humans do err. However,
it is due to this fact that
there is a need to detect
these errors and also
develop safeguarding
systems to prevent them
from becoming an
accident [3]
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 Applies to all workers (management,
contractors, operators, engineers, etc.) [3]
 Often tied close to human resources
personnel:




Conduct
Consequences
Fitness of duty assessment
Disciplinary actions
Salary & bonuses
Retention decisions
 Authority, accountability and work
performance indicators should be defined
 May be coordinated with other element outputs
 Equipment status for asset integrity
 Near miss reports for incidents element
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16. Emergency
management
The emergency management element
involves planning for emergencies,
practicing them, training employees,
contractors and local authorities, as well
as communicating with local stakeholders.
157
 Protect people onsite and offsite including
emergency responders [3]
 Planning & training
 Drills
Objectives
 Communicate with stakeholders before an incident
 Planning & coordination
 Communicate with the media in the event of a
serious incident
 In conjunction with the stakeholder communication
element (element # 5)
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 Planning
 Create emergency procedures such as shutdown,
isolation of hazardous materials [3]
 Create emergency evacuation plans
 Assess the need for emergency management
equipment on site such as:
Protecting
people
 Blast walls
 Fire fighting equipment
 Plant alarms, etc.
 Training
 Train all staff and contractors on the developed
procedures and facility evacuation plan
 Drills
 Periodically test the readiness of the operators and
contractors to safety shutdown and evacuate the
facility
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Planning
 How much a facility will want to depend on
municipal emergency responders [3]
 Preventative vs. Mitigative safeguards
Coordination
with
Municipal
Crews
 Regain control with preventative safeguards to
prevent incident
 Reduce impact of incident with mitigative
safeguards
Communication
 Make important information available to municipal
crews to protect their safety if an incident occurs
(flammables on site, toxic fumes, etc.)
 Establish a system for ensuring a quick response in
the event of an incident
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 Emergency management will
involve many people from all
levels of the organization [3]
 Immediate actions will be taken
by operators:
 Shutdown the process
 Isolate hazardous materials
Scope
 Further actions will be
coordinated by an incident
commander
 Coordination of specialist
teams such as HAZMAT or Fire
fighters
 Order evacuation
 This person should have
experience in emergency
decision making
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In the event
of an
incident
Introduction
An effective emergency management system will do
the following things in the event of a loss of
containment incident [3]:
 Save lives
 Protect property & the environment
 Reassure stakeholders that the facility is properly
managed and should be allowed to continue
operating
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Required by law:
 Canadian Environmental
Protection Act (CEPA)
Emergency
Management
Systems
(EMS)
Good business Sense:
 Damage to reputation
 Customers
 Employees
 Community
 Cleanup costs
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Loss of life may not have been so high if more
effective emergency management was present [3]:
 All personnel authorized to order evacuation were
killed in the first blast.
Piper Alpha
Continued
 This was due to the fact that the control room
where they were located did not contain any blast
walls. Poor emergency management design
 Personnel with authorization to evacuate the
facility should not be located together
 The workers who did not evacuate and were
sheltered in the galley were all killed
Introduction
Commitment
to PSM
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 Operators were not aware of any procedures to shutdown
the process or isolate the hazardous materials [3]
 Operators did not believe they had the authority to shut
down the process even though they could see the rig was
on fire
 This was the direct cause of the second explosion
 This was due to a lack of emergency procedures
Piper Alpha
Introduction
 Evacuation routes were blocked by enormous flames
(helicopters)
 Lack of coordination with government emergency crews
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 [1] Trevor Kletz. Plant design for safety: a user friendly
approach. Hemisphere Publishing Corporation: New York,
1991.
 [2] Trevor Kletz. Process Plants: A Handbook for Inherently
Safer Design. CRC, 1998.
 [3] Center for Chemical Process Safety. Guidelines for Risk
Based Process Safety. New Jersey : Jon Wiley & Sons, 2011.
References
 [4] National Transportation Safety Board. Aircraft accident
report: American Airlines, Inc. DC-10-10, N110AA. Chicago
O'Hare International Airport Chicago, Illinois, May 25, 1979.
Report 20594, 1986.
 [5] Center for Chemical Process Safety. Guidelines for
Management of Change. New Jersey : Jon Wiley & Sons,
2008.
 [6] Oil & Gas UK. Piper Alpha: Lessons Learnt, 2008.
 [7] Chitram Lutchman, Rohanie Maharaj, & Waddah
Ghanem. Safety Management: A comphrensive approach to
developing a sustainable system. CRC Press: Florida, 2012.
 [8] Center for Chemical Process Safety. Guidelines for
Management of Change. New Jersey : Jon Wiley & Sons,
2008.
166
Enhancing PSM
 Incident Investigation
 Measurement and Metrics
 Auditing
 Management Review and Continuous Improvement
 Implementation
 The most effective PSM systems use new
information as it becomes available over the
lifetime of the process to continuously improve the
PSM system [1]
Continuous
improvement
 Enhancing PSM is based on learning from
experience
 This is typically done through:
 Investigating incidents or near misses that occur and
addressing their root causes
 Apply lessons learned from other similar facilities
 Measuring performance
 Auditing the PSM system
 Performing management reviews
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17. Incident
Investigation
As it sounds, this element is about
investigating any incidents or near misses
to determine the root cause (if possible)
and applying this information to improve
the PSM system
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 Formal accident reporting, tracking, and
investigation system [1]
Process
 Analyzing incident trending
 Learn from experience – apply newly acquired
information if appropriate
Introduction
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 This system is not for blaming employees and
results should not be treated as such [1]
 It should be approached as a mechanism for
addressing the underlying system procedures or
process cause
Organization
Culture
Introduction
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18. Measurement
& Metrics
This element focuses on measuring and
assessing the actual performance of a
process and not the intended performance
which may become misleading over time.
172
 Metrics are indicators of system
performance [2]
Metrics
 Incidents frequency is not
effective indicators for
proactive process
improvement
 It is often used for reactive
process improvement,
however, proactive prevention
should be best practice
 Types of measurements and
frequency of updating indicators
is facility and process specific
 Depends on cost, local needs,
the type of process, risk level,
operational dynamics,
commitment to process
safety
Introduction
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• Easier to take corrective actions proactively, therefore
use leading indicators [2]
• We call these Key Performance Indicators (KPIs)
KPIs
 There may be some
mandatory
requirements for KPIs
for a particular
process or piece of
equipment and this
should be taken into
account.
• This element can often be combined with other
business metrics such as efficiency, cost analysis, and
productivity
Introduction
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Leading
 Input measurements which are typically hard to
measure but easy to influence. This type of
improvement is pro-active [1]
Leading &
Lagging
Indicators
 Measures the barrier’s strength and maintains it to
prevent incidents in the Swiss Cheese Model of PSM
failure
Lagging
 Output measurements that are easy to measure but
difficult to improve. This type of improvement is
reactive
 Measures the protective barrier defects and the
events and consequences in the Swiss Cheese
Model of PSM failure
Introduction
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Indicators
Which is leading/lagging [2]?
 Weighing yourself on a scale
Example –
Losing
Weight
 Easy to measure
 Difficult to take corrective
action
 Counting your consumed
calories and your expended
calories
 Difficult to measure
 Easy to take corrective action
Introduction
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• Long term documentation
is dependent on [2]:
• Process risk
• KPI measurement
Regulatory requirements
Documenting
&
Reporting
Introduction
 Often, government or
professional associations
(such as Responsible Care)
will require the reporting of
some KPIs
 This allows them to develop
new metrics or
recommendations for all
facilities in order to improve
the safety of whole
industries
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19. Auditing
This element is critical in assessing the
effectiveness of the PSM system. It should
identify weaknesses in the design or
implementation, and use this information
to correct them.
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 Independent
 Systematic
 Comparison of current process
to Standards of Care
 Guidelines which include
standards, regulatory
requirement and other
external rules
 Internal self-imposed
requirements
What is an
Audit?
 Auditing is most often used
during the operating phase of
a facility
[1]
Introduction
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How often audits are conducted will depend on
several factors [1]:
 Process inherent risk
 Phase process life cycle
 Past experience
Frequency
 Maturity of the PSM system
 Maturity of organizational culture
 Facility, corporate, or regulatory requirements
Regardless, some audits should be conducted on a
regularly scheduled basis such as once a year
Introduction
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 Team based activity [1]
 However, requires access to operators and experts
 Team should be lead by competent personnel
 Element by element (typically)
Who & How?
Scope
 Directed primarily by documented protocols
Physical Scope – What element or units are being
audited?
Analytical Scope – What are the auditing criteria?
Temporal Scope – What time period are you
auditing? E.g. April 1, 2013 - March 30, 2013
Introduction
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 Audits are not useful on their own [1]
 Findings must be used to improve PSM
Implementing
Audit Findings
Introduction
Commitment
to PSM
 Adopt as proposed
 Adopt in principle (the recommendation will be
implemented in an equivalent manner)
 Reject based on the assertion that the
recommendation was made in error (Because of an
error in facts or in judgement)
 Reject due to a change which has rendered the
recommendation inapplicable.
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20. Management
Review and
Continuous
Improvement
This element focuses on the routine review
of management systems for effectiveness
and ability to produce the desired results
183
What is a management review?
 Like an audit, but less formal, more frequent, and the reviewers are generally
in-house employees
 Breakdowns in management systems are harder to detect and slower to be noticed
 For example:




The training coordinator unexpectedly leaves
The trainers continue to train people and the element seems intact
A management review revels that some workers or contractors are overdue for training
At that point it could be too late…
Introduction
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Hot work Explosion, Delware, 2001
 Catwalk above sulphuric acid tank needed
welding repair. The sulphuric acid tank
below had holes and was in a poor state
of repair [1,3]
 1 contractor killed and 8 others injured as
a result of the explosion
 Large volume of sulphuric acid was
released into the environment
Introduction
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Management Review
 Hazards were not assessed correctly since the tank
was changed from normal acid service to spent acid
service (corrosivity & flammability hazards changed)
[1]
Root Cause
 Sulphuric acid tanks were not maintained properly
and requests for maintenance were always ignored
or deferred
 Previous requests for hot work were denied due to
toxic and sufficient flammable gas concentrations
 The hot work permit did not specify atmospheric
monitoring despite previous permits being denied
for this reason
Introduction
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Remember –The elements work together!
[1,4,5,6]
187
 [1] Center for Chemical Process Safety. Guidelines for
Risk Based Process Safety. New Jersey : Jon Wiley &
Sons, 2011
 [2] Karel van der Poel. Lagging and leading indicators.
http://kpilibrary.com/topics/lagging-and-leadingindicators Accessed Nov 9, 2013.
References
 [3] U.S. Chemical Safety and Hazard Investigation
Board. INVESTIGATION REPORT. REPORT NO. PB2002108210.
http://www.csb.gov/assets/1/19/Motiva_Final_Report
.pdf Accessed Nov 9, 2013.
 [4] Trevor Kletz. Plant Design for Safety: a user friendly
approach. Hemisphere Publishing Corporation, 1991
 [5] Canadian Society for Chemical Engineering.
Process Safety Management Guide. Ottawa : Canadian
Society for Chemical Engineering, 2012.
 [6]. Energy Institute. High Level Framework for Process
Safety Management. London : Energy Institute, 2010.
188